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Arquivos Brasileiros de Cardiologia - Volume 85, Nº 1, Julho 2005
Case Report
Eikenella Corrodens
Infective Endocarditis
Juliano Novaes Cardoso, Marcelo Eidi Ochiai, Múcio T. Oliveira Jr., Paulo Morgado,
Robinson Munhoz, Fernanda E. Andretto, Alfredo José Mansur, Antonio Carlos Pereira Barretto
Instituto do Coração do Hospital das Clínicas - FMUSP - São Paulo, SP - Brazil
Mailing address: Juliano Novaes Cardoso - Rua Ministro Gastão Mesquita, 725/83 - 05012-010 - São Paulo, SP - Brazil E-mail: julianonc@hotmail.com, cardiopulsar@hotmail.com Received for publication: 04/21/2004
Accepted for publication: 02/10/2005 English version by Stela Maris Costalonga
The HACEK microorganisms (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corro-dens, and Kingella kingae) account for 3% of the cases of endo-carditis. They have the following similar clinical and microbiological properties: are Gram-negative bacilli, more easily isolated in aerobic media; their cultures require prolonged incubation time for growing (mean, 3.3 days); and may be considered part of normal flora of the upper respiratory tract and oropharynx1,2. The following
charac-teristics have been identified in endocarditis caused by the HACEK microorganisms: insidious clinical findings 1; difficult diagnosis
due to the fastidious nature of the microorganisms; and negative cultures3,4.
The Eikenella corrodens endocarditis was first described in 19725. That microorganism continues to be a rare etiological agent.
We report the case of a female patient with native valve, who had Eikenella corrodens infective endocarditis.
Case report
The patient is a 32-year-old female, who sought medical care complaining of daily fever of up to 39o C and loss of appetite for
one week.
The patient had been previously diagnosed with rheumatic valve disease, but was not under medical follow-up.
On physical examination, the patient had a regular general condition, was eupneic, and pale (+/4+). Her axillary temperature was 38o C, her heart rate was 90 bpm with water-hammer
pul-se, and her blood pressure was 120 x 20 mmHg. The lung exa-mination showed no alterations. Her cardiac exaexa-mination showed a regular heart rhythm, systolic murmur (4+/6+) in the aortic area, irradiating to the left sternal margin and mitral area, and diastolic murmur (3+/6+) in the aortic area. Her dental assess-ment revealed a poor condition.
Her hemogram was as follows: hemoglobin, 10.4 g/dL; hema-tocrit, 30%; leukocytes, 7,800; and platelets, 120,000. Her creati-nine level was 0.9 mg/dL, and fasting glycemia was 120 mg/dL. The type 1 urine test showed no leukocyturia.
The electrocardiogram showed sinus rhythm, and hypertrophy of the left chambers. Chest radiography showed an enlargement of the cardiac area, and pulmonary fields with no alterations.
The transthoracic echocardiogram showed left ventricular dia-meter of 5.3 x 2.7 cm, and left atrial diadia-meter of 4.6 cm. In addition, the transesophageal echocardiogram showed an extre-mely calcified tricuspid aortic valve, with decreased mobility and marked double dysfunction. At the level of the valvar ring, an image was observed, projecting to the coronary sinus, with a rough as-pect, but with echogenicity close to that of calcium, which was compatible with chronic vegetation.
No microorganism grew in the first 2 samples of blood culture. We chose to wait for the etiological diagnosis before initiating the antimicrobial treatment.
Two days after admission, a new hemogram revealed 16,100 leukocytes with 90% of neutrophils. New samples were collected for blood culture. As the patient’s clinical condition deteriorated, therapy with crystalline penicillin and gentamicin was initiated.
Her general condition improved with the antibiotic therapy, but the fever persisted. Five days after introducing the antibiotics,
Eikenella corrodens was identified in the 3 pairs of blood culture collected in the aerobic balloon. The treatment was changed to ceftriaxone, 2 g per day. The patient improved. The antibiotic treatment lasted 6 weeks. The patient was discharged from the hospital, and, after 40 days, she was back to her usual activity.
Discussion
This clinical case allows the analysis of interesting aspects of
Eikenella corrodens endocarditis, such as diagnosis, rare etiological agent, and response to medicamentous treatment.
The frequent empirical use of antibiotics, even before adequa-tely collecting blood culture, considerably hinders the diagnosis, because the use of antibiotics decreases the sensitivity of the test. In our case, as the blood cultures were correctly collected, the bacterium could be identified. It had a slow growth, charac-teristic of the E. group. The accurate microbiologic diagnosis is known to be very important for the adequate choice of the anti-microbial agent6.
Infections caused by bacteria of the HACEK group should be suspected in patients with history of periodontal disease or recent dental treatment1,4.
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Arquivos Brasileiros de Cardiologia - Volume 85, Nº 1, Julho 2005
Eikenella Corrodens Infective Endocarditis
1. Berbari EF, Cockerill FR, Steckelberg JM. Infective endocarditidis due to unusual or fastidious microorganisms. Mayo Clin Proc 1997; 72: 532-42.
2. Burger JA, Messineo FC, Schulman P, Geller D. Mycotic aneurysm of the sinus of val-salva due to Eikenella corrodens bacterial endocarditis. Cardiology 1984; 71: 220-8. 3. Zbinden R, Hany A, Conen D, Heinzer I. Antibody response in six HACEK
endocar-ditis cases under therapy. APMIS 1998; 106: 547-52.
4. Watkin RW, Baker N, Lang S, Ment J. Eikenella corrodens infective endocarditis in a previously heathy non-drug user. Eur J Clin Microbiol Infect Dis 2002; 21: 890-1.
References
5. Landis SJ, Korver J. Eikenella corrodens endocarditis: case report and review of the literatute. Can Med Assoc J 1983; 128: 822-4.
6. Taubert KA, Dajani AS. Optimisation of the prevention and treatment of bacterial endocarditis. Drugs Aging 2001; 18: 415-24.
7. Wilson WR, Karchmer AW, Dajani AS et al. Antibiotic treatment of adults with in-fective endocardites due to streptococci, enterococci, staphylococci, and HACEK microorganisms. JAMA 1995; 274: 1706-13.
The lingering clinical evolution of our patient with good res-ponse to antibiotic therapy was similar to that of cases reported in the literature.
